CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
The Impact of Community Faith-Based Initiatives to Support Latino Mental Health
A graduate project submitted in partial fulfillment of the requirements
For the degree of Master of Social Work
By
Ana Luiza Nogueira
May 2020 The graduate project of Ana Luiza Nogueira is approved:
______Dr. Ioana Schmidt Date
______Dr. Maria Acuña Date
______Dr. Jodi Brown, Chair Date
California State University, Northridge
ii Dedication
To my family and friends who supported me along my journey. Obrigada!
To Proyecto Esperanza, to Elvia Hernandez, and to all the Latino parents who work tirelessly to support their families and community. Gracias!
A educação (...) é a prática da
liberdade – o meio através do qual
homens e mulheres lidam crítica e
criativamente com a realidade e
descobrem como participar da
transformação de seu mundo.
Education (...) is the practice of
freedom, the means by which men
and women deal critically and
creatively with reality and discover
how to participate in the
transformation of their world.
(Freire, 2000, p.15)
iii Table of Contents
Signature Page ii
Dedication iii
Abstract v
Introduction 1
Method 8
Results 15
Discussion 27
References 38
Appendix A: Characteristics of Study Sample 45 Appendix B: Research Invitation 46 Appendix C: Interview Protocol 48 Appendix D: Project Esperanza Mental Health Workshop Agenda 50
iv
Abstract
The Impact of Community Faith-Based Initiatives to Support Latino Mental Health
By
Ana Luiza Nogueira
Master of Social Work
Oppressed groups encounter several social barriers that mitigate their ability to access services. As such, Latinos have historically underutilized mental health services and often turn to faith-based organizations for support. This grounded theory study sought to analyze the impact of faith-based mental health literacy interventions on Latino mental health. Qualitative interviews with Latinos from the community of Santa Paula were used to generate data and results were evaluated through social constructivism and intersectionality lenses. Findings demonstrated that the impact of faith-based initiates on Latino mental health extends past the individual level to the family and community level, ultimately leading to development of mental health literacy, improved parenting practices, break of intergenerational stigma, and engagement with formal services. In this context, faith-based initiatives can serve as a bridge between Latinos and the historically underutilized services, while creating opportunities for social workers to employ micro, mezzo, and macro-level skills to foster social justice.
Keywords: Latinos, Mental Health Literacy, Faith-Based Services
v Introduction
Research Problem
Latinos comprise the nation’s largest ethnic minority group with 58.9 million residents, approximately 18.1% of the total population (U.S. Census Bureau, 2018). Although Latino communities show similar susceptibility to mental illness as the general population (Escovar et al.,
2018; National Alliance on Mental Illness, n.d.), studies demonstrate that they have underutilized mental health services (Alegría et al., 2008; Kouyoumdjian et al., 2003; Substance Abuse and
Mental Health Services Administration [SAMHSA], 2018). By employing an intersectionality lens
(Carbado et al., 2013), it is possible to grasp how minority groups who present several marginalizations, are subject to additional and unique socioeconomic and cultural barriers to accessing services. Barriers that often prevent Latinos from engaging in mental health services include financial stress, lack of available time, health insurance, collectivist attitude, language, perceptions of mental health, privacy, and lack of ethno-culturally appropriate practices
(Kouyoumdjian et al., 2003).
Despite numerous barriers, Latinos have several strengths, including spirituality. Faith- based organizations (FBOs) play a major role in Latino communities and are often associated with support, hope, and acceptance (Villatoro et al., 2016). Throughout the years, FBOs have not only provided spiritual support, but also emotional, educational, and more recently even mental health support, as Wong and colleagues (2018) found that 23% of the nation’s congregations provide some sort of mental health program. In this context, faith-based programs become a bridge between Latino families and the often underutilized formal mental health services.
1 Purpose of the Study
Latinos comprise 81.3% of all residents in the city of Santa Paula, compared to 43% of
Ventura County overall (U.S. Census Bureau, 2010). The high concentration of Latinos in this town calls for cultural humility and social justice practices that tackle barriers experienced by this group. Under such circumstances, the Project Esperanza held at Our Lady of Guadalupe Church, acts as a major community resource that provides education, sports, and cultural preservation.
Funded by the Department of Mental Health and the Mental Health Services Act of Prevention and Early Intervention, the project holds free mental health literacy workshops in partnership with local mental health practitioners and advocates, targeting parents of children enrolled in the after school program and aiming to increase awareness and reduce stigma.
In light of the significant number of Latinos in our community that often underutilize services, and the importance of faith-based services to this particular group, this study seeks to investigate the impact of mental health literacy workshops held by an FBO on Latino individuals.
This research will contribute to the social work field by providing a deeper understanding of the experiences of Latinos and how faith-based initiatives can support their mental health.
Research Question
This study asked how participation in a faith-based mental health literacy program impacts Latino individuals. More specifically, the study explored how it affected their attitudes toward mental health, sense of social support, and knowledge of community resources.
2 Literature Review
Impacts of Mental Illness
Mental health encompasses more than the absence of illness, but rather a comprehensive state of well-being, ability to cope with stressors, engage in meaningful activities, and contribute to the community (World Health Organization [WHO], 2005). The SAMHSA (2018) reports that in 2017, an estimated 46.6 million adults in the United States had a mental illness, representing
18.9% of adults in the country. Such conditions can range from mild to severe, leading to several consequences for the individual and for the community as a whole.
Studies show that Latinos present lower levels of mental health literacy (Caplan & Cordero,
2015) and are less likely than non-Hispanic Whites to seek mental health support (Zuvekas &
Fleishman, 2008). When they do seek mental health help, they report higher levels of somatization and physical functional impairment than non-Latinos (Escovar et al., 2018). Somatization is known to be an appropriate way of expressing distress within certain cultures (Kirmayer & Young, 1998), yet it might also be a way of preventing stigmatization often found within collectivist cultures
(Keyes & Ryff, 2003), and a product of symptom suppression due to discrimination (Ayón et al.
2010). Since Latinos present distinctive attitudes toward mental health, specific interventions such as mental health literacy are needed to facilitate access to services.
Mental Health Literacy
Health literacy is the achievement of knowledge, skills, and confidence to take action to improve personal and community health (WHO, 2019). Higher levels of health literacy are associated with decreasing health inequalities, enhancing health systems and developing better health policies (Furnham & Swami, 2018). Similarly, the term “mental health literacy”—first
3 coined by Jorm and colleagues (1997)—refers to the public knowledge and beliefs about mental health that can assist with symptom recognition, management, and prevention.
Considering that the general population tends to choose self-help over traditional medical treatments (Furnham & Swami, 2018), and that ethnic minority and migrant groups show lower levels of mental health literacy than majority groups (Mori et al., 2007), initiatives that promote mental health literacy for minority groups become a paramount intervention to spread awareness, reduce stigma, prevent symptoms, empower individuals to make informed choices, improve help- seeking behavior, and link families with formal treatment.
Faith-Based Mental Health Literacy Initiatives
Churches, synagogues, mosques, and temples serve as a place of worship and offer support to a significant part of the population. The trust developed in these environments is so significant that, when faced with a challenge such as mental illness, 25% of people turn first to clergy for support (Wang et al., 2003). This is particularly true among the Latino population (Villatoro et al.,
2016). Thus, Caplan and Cordero (2015) argue that involvement of the faith-based community should be a fundamental piece of mental health literacy interventions to improve treatment engagement. From this perspective, it was found that faith-based mental health literacy initiatives can reduce mental illness stigma in minority and underserved communities (Brown, 2009; Jozaghi et al., 2016), increase mental health awareness and knowledge of treatment service (Crewe, 2006;
Pickett-Schenk, 2002), and improve morale (Pickett-Schenk, 2002) among participants.
Despite a large number of faith-based coalitions and collaborative partnerships recognized by SAMHSA (2019), there is a lack of documented practices in the literature using a qualitative research method focused on the effects of such interventions on minority groups, including
Latinos. As the WHO (2019) argues that in order to increase levels of health literacy academic
4 research should focus on investigating best practices in health literacy interventions, this research extends the existing literature and fills some of the existing gaps by giving voice to the Latino community of Santa Paula, and generating in-depth knowledge about the practices of the Project
Esperanza’s mental health literacy program.
Theoretical Framework
Developed by Vygotsky (1978), social constructivism proposes that language and culture play significant roles in intellectual development and in how one perceives the world. Thus, knowledge and meaning are co-constructed through interaction with others and through historical and cultural norms. With a deep focus on the research participants’ worldview, social constructivism leads participants to develop meaning of a situation, while focusing on the specific contexts in which they are inserted, taking into consideration their historical and cultural aspects
(Creswell & Poth, 2018). Based on this framework, the interview process will aim to investigate how participants’ life experiences (what was learned from their family upbringing), interactions with society (academic, occupational and religious experiences as a minority group), and cultural norms (collectivism and familismo) shaped their understanding and views on mental health, as well as their ability to access services.
An intersectionality framework will be used as an additional lens considering that the participants present nationality, language, immigration status, race, ethnicity, and socioeconomic identities that cannot be ignored as they intersect and directly shape their experiences.
Intersectionality theory (Crenshaw, 1989) posits that multiple marginalizations intersect resulting in complex forms of inequality and as such cannot be analyzed separately. The term intersectionality was first introduced by Crenshaw (1989) in the context of the experience of Black women with racism and sexism in the legal arena, and since then, research has expanded the
5 framework to include a range of issues, social identities, power dynamics, and legal and political systems (Carbado et al., 2013). A cornerstone of intersectionality-informed qualitative research is its ability to advance social justice by steering away from obtaining statistical results and moving towards understanding and addressing inequality (Hunting, 2014).
When integrating intersectionality in the research process, Cole (2009) argues that researchers should consider what role inequality plays on the individual and structural level, and how systems of privilege, power, and inequality occur within contexts. For instance, research among Latinos should not only consider the unique demographics (nativity, race, and gender), but also consider the underlying systems of immigration stress, and ethnic, gender, and socioeconomic discrimination (Shin et al., 2017). This process is essential to avoid narrow understandings and reinforcement of reductive assumptions, which can unwittingly exacerbate health disparities
(Hunting, 2014).
Intersectionality will be employed to promote in-depth data analysis of the individual experiences of the participants, rooted in their multiple identities that intersect and unfold particular strengths and barriers. For instance, an older immigrant woman monolingual Spanish speaking of low socioeconomic status who is the primary caregiver of her grandkids who are part of the Project Esperanza may have a very different experience than a third-generation Latina cisgender woman who is attending college and is a single mother for a child who is part of the
Project Esperanza. Although both are Latina women, they may present distinct experiences in regards to the level of acculturation, documentation status, ability, and education. Thus, their identities intersect in unique ways yielding privileges and oppressions that shape the way they experience life, assign meaning, and construct views on mental health.
6 By concurrently implementing an intersectionality and social constructivism framework, this research will not only analyze the findings based on the way participants assign meaning to their experiences and view the world, but also based on the fluid identities and interlocking systems of oppressions that shaped the way they learned, experienced, and accessed mental health. Finally, since social constructivism also takes into consideration the investigator’s own biases, experiences, and worldviews that shape the way the findings are interpreted (Creswell & Poth, 2018), the researcher will use a reflexive journal to explore one’s assigned meanings in the context of one’s own intersectionality identities and how it shapes the research findings and interpretation.
7 Method
Research Design and Sampling
Since research studies should be conducted to fill the literature gaps, improve current practices, and learn from marginalized groups whose voices have not been heard (Clark &
Creswell, 2015), a qualitative design with a grounded-theory approach was employed to obtain in- depth knowledge of the subjective experiences, to develop a theory to explain the practice, and to serve as a vehicle to magnify the voices of the participants. Developed by Glaser and Strauss in
1967, grounded theory methods entail systematic, yet flexible guidelines for collecting and analyzing qualitative data, aiming to move beyond description and to construct theories from the data themselves—shaped by the views of participants—that might help explain practice or provide a framework for further research (Charmaz, 2014; Creswell & Poth, 2018).
The sample consisted of five Latino adults who participated in the Mental Health
Workshop from Project Esperanza in the city of Santa Paula. Purposive sampling was employed to ensure that the participants were able to purposefully inform and understand the research phenomenon (Creswell & Poth, 2018). This research was approved by the Committee for the
Protection of Human Subjects at California State University, Northridge, and ethical considerations were addressed across the data collection process, specifically regarding respect for persons, concern for welfare, and justice (Creswell & Poth, 2018). A pseudonym was assigned to each participant throughout this study in order to preserve their anonymity, and brief vignettes about the participants were created to bring the reader closer to participants’ realities.
“Adriana” identifies as a Latina, immigrant, woman, able-bodied, and of middle class. She is Spanish speaking and is learning English. She completed High School in Mexico and did some
8 college. She is a stay-at-home mother and a caregiver for her child and for her aunt who has a different ability. She is 40 years old, married, and has one child.
“Valentina” is a 39-year-old able-bodied Latina woman who immigrated to the United
States 15 years ago. She completed technical school in Mexico and works part-time. She is married and has three children. She is Spanish speaking and is learning English.
“Isabel” is a 45-year-old Spanish speaking able-bodied Latina woman who works full-time and is a caregiver for her father. She completed secondary school (middle school) in Mexico and at age 15 she moved to the United States, where she completed high school. She is married, has four children, and finds purpose in helping others.
“Carmen” is a 48-year-old able bodied Latina woman who completed secondary school
(middle school) in Mexico and immigrated 17 years ago. She is a stay at home mother, is married, and has two children. She takes English as a second language class and enjoys baking.
“Sofia” is a 47-year-old able-bodied Latina woman who completed preparatory school
(high school) in Mexico and is currently taking English as a second language class. She is a stay- at-home mother, is married, and has two children. She always dreamed about becoming a lawyer or teacher, and is currently engaged in her children's school English Learner Advisory Committee.
Data Collection
Data was collected via Spanish audio recorded one-on-one interviews, which play a central role in grounded theory studies (Creswell & Poth, 2018), and participants were reminded about the purpose of the research, limits of confidentiality, and resources available if emotional distress was experienced. Interviews were conducted in January 2020 at the participant’s preferred setting—three participants chose their home, while two chose a public place such as a library—
9 and recordings ranged from 45 minutes to 99 minutes. The researcher translated and transcribed each interview within five days.
The researcher strove to practice cultural humility and be sensitive to each participant’s cultural and personal context. Especially in the interview that were conducted at their homes, the researcher followed Latino-family values, such as personalismo, in which people expect a warm, personal regard with people with whom they are interacting (Allen & Spitzer, 2016), and is a way to bridge differences among people (Evans et al., 2007). The personalismo was observed by the researcher as participants had a warm and welcoming affect, and treated the researcher as family, as evidenced by comments such as “now that you know where I live, you are welcome to come in at any time.” At the end of each interview, participants were provided with a gift card as appreciation for their willingness to participate in the research.
Measurement
Participants were asked to provide basic intersectional demographic information regarding their age, ethnic origin, ability, language, gender, marital status, household composition, education and occupational status (Table 1). The interview was guided by a semi-structured interview protocol (Appendix B) based on the Mental Health Literacy Scale (O’connor & Casey, 2015) in order to assess knowledge and attitudes toward mental health and help-seeking, being a good instrument to analyze mental health literacy programs (O’connor & Casey, 2015). Additionally, the researcher used organizational documents to supplement the data collection and expand knowledge regarding the program, and also performed observations to strengthen the findings. By attending the workshop, the researcher had the opportunity to participate and observe participants in their social world (Charmaz, 2014). Social world is composed by individual actors who bring personal interests and commitments to action, to sharing resources to achieve their goals, and to
10 building shared ideologies (Clarke, 1991), thus in this context, the researcher was able to observe the Latino parents who shared the common interest of learning about mental health, and were determined to learn and share skills, engage in mutual help, and implement change in their lives to support their offspring’s mental health.
In order to mitigate power asymmetry between interviewer and interviewee (Creswell &
Poth, 2018), the interviewer strove for a collaborative interview, allowing the participant to equally approach questioning, interpreting, and reporting. Credibility, authenticity, criticality, and integrity were employed in this study to foster validity (Whittemore et al., 2001). To ensure credibility, reflective listening was used to verify the interpretation of the participant’s answers.
Authenticity was employed by warranting that different participant voices were heard. Criticality was ensured by critically appraising the research findings, and integrity was fostered by applying reflexivity. A reflexive journal (Creswell & Poth, 2018) was used throughout the research process to allow the principal investigator to reflect on the findings, and to gain awareness of the researcher’s own worldview, biases, intersectionality, privileges, and shared marginalizations that may have shaped how research findings are interpreted. Finally, reliability was promoted via detailed field notes, good-quality audio recording devices, transcription of the digital files, careful coding, and the use of a reliable computer-assisted qualitative data analysis software (CAQDAS).
The Atlas.ti CAQDAS facilitated the coding process, in which labels were attached to segments aiming to categorize, summarize, and account for each piece of data, making analytic sense of the participants’ statements (Charmaz, 2014). The initial phase involved line-by-line coding, naming each segment of data with provisional words that reflected action in order to preserve the participants’ experience and meaning. This also led the researcher to pursue subsequent data collection to fill gaps until saturation was reached. Finally, the researcher used
11 focused coding to sort, synthesize, and analyze the large amounts of data, creating categories and subcategories and moving from a descriptive to a conceptual analysis, which led to the development of a theory (Charmaz, 2014). A constant comparative approach (Glaser, 1965) was also used as it aims to suggest properties and hypothesis about a general phenomenon. It comprised stages of comparing emerging data incidents, writing memos, integrating categories, delimiting the theory and writing the theory.
As several close to data codes emerged during the coding process, the researcher was able to create subcategories. In this process, the researcher noticed that the codes were related to outcomes on the individual, on the family, and on the community, allowing for the development of an ecological conceptual model to represent the findings.
Project Esperanza’s Mental Health Workshop
Based at Our Lady of Guadalupe Church, the Project Esperanza provides several services to the community of Santa Paula. Striving to provide a safe and nurturing environment for children to develop social skills while engaging in leisure, physical and cultural activities, the project launched an after-school program in which families enroll their children on a variety of activities such as folk dance, taekwondo, and piano and guitar lessons. In return, caregivers are encouraged to attend the free Spanish mental health workshops facilitated by volunteer clinicians and mental health advocates. Different topics on mental health are explored each month (mental health and stigma, wellness, technology and mental health, cyberbullying and self-esteem, anxiety and depression, self-injurious behavior, suicide prevention, children’s mental health, and men’s mental health) with a focus on prevention, knowledge building, and stigma reduction (Appendix C).
The researcher observed a workshop in January 2020, facilitated by a Social Worker from
Ventura County Behavioral Health and focused on anxiety and depression. Participants were nine
12 women and one young male who was with his mother, and the environment was welcoming. While using a variety of teaching methods, the facilitator normalized mental health symptoms and presented the topics in an accessible way, providing information on symptoms, levels of impairment, causes, prevalence, stigma, prevention, treatment, where to seek help, effective communication and parenting skills. The facilitator talked about somatic symptoms (which are often reported among Latinos), and about the difference between men and women in seeking mental health services. The facilitator encouraged participants to reach out to Project Esperanza as they can link them to resources and provide a warm hand-off, and emphasized the importance of advocating, asking questions, and requesting resources when meeting with a mental health provider.
Participants were observed as engaged and appeared comfortable to ask questions and share personal experiences. In the end, the Project Coordinator encouraged them to share the information with their families and communities, to continue engaging their children in the project, and to attend the next workshops. Some participants individually approached the facilitator to ask questions and ask for mental health services. The workshop facilitator shared with the researcher that participants often approach them after the workshop and disclose stressors that the family has been experiencing. This is an opportunity for the facilitator to provide further information about mental health services and develop the “confianza” (trust), and this intervention has been effective in linking participants to the outpatient mental health clinics in the community.
The researcher also met with the Program Coordinator who emphasized that the Mental
Health Literacy workshop has the capacity to reach many people since it is inserted in the faith- based organization. She highlights the importance of spirituality and mental health care working together since individuals often disclose mental health related stressors to faith leaders as there is
13 a relationship of confianza (trust). Through the cleric seminary and education, faith leaders are capable to identify signs that might be related to mental health, such as “tristeza” (“sadness”, often related to depression) and “nervios” (“nerves”, often associated with anxiety). Thus, faith leaders link congregants to Project Esperanza, which is able to use the warm hand-off and connect them with formal mental health services.
14 Results
Enacting a purposeful sampling design, all five participants were women, immigrants, from Mexico, married, mothers, with a mean age of about 44 (Table 1). Three of them were full- time caregivers, and two also held part-time or full-time jobs. Data from the interviews pointed to the impacts of faith-based initiatives on several levels. Major themes that emerged were the impact on the individual (subthemes of mental health literacy and developmental of support system), impact on the family (subthemes of improved parenting practices and break of intergenerational stigma), and impact on the community (subthemes of mental health awareness, engagement services, and advocacy).
Impact on Individual
Mental Health Literacy
Participants described developing mental health literacy (MHL) skills through participation in the workshops. Different subcategories of MHL emerged, as below:
From “Están Locos” to “We All Need Help”. The emerged theme “están locos” (“they are crazy”) was reported multiple times by all participants and is related to the understanding of mental health that was developed throughout their upbringing and lived experiences. Stigma and taboo were closely associated with mental health, as Sofia explained that, “If we talked about mental health we were talking about ‘locos’ (crazy). It has always been a myth. If we heard someone say, ‘so and so is sick on the nervios (nerves)’, people would say, ‘ay, está loca.’ ”
Similarly, Valentina shared that, “In Mexico, mental health is ‘one is not well on the head’, ‘está loco’ (“one is crazy”), ‘don't get close because they are crazy.’ ”
Participants talked about the impacts of stigma on the individuals who are seen as having mental health issues. Adriana mentioned that when the community would call someone “crazy”,
15 that person would be “marked”, and then start to internalize the stigma: “one says, ‘oh, well, she said I’m crazy’, and one grows up with the mentality that ‘oh, I’m crazy, I’m crazy.’ ” This conveys how societal stigma affects the way individuals develop beliefs about themselves.
The reported stigma not only affects individuals but also entire systems of services, including how practitioners approach mental health services. Sofia recounted how services were approached in her hometown in Mexico, “No doctor tells you to see a psychologist to help you get out of depression. Because they know that people will say, ‘the doctor thinks that I’m crazy, they will take me to a clinic for crazy people’.” This shows how practitioners refrain from referring people to services due to the perceived cultural stigma.
Carmen added that mental health had always been a taboo, something that people do not talk about: “[Growing up] I didn’t hear anything about it. In Mexico, one doesn’t realize what depression or anxiety is. This is not talked about.” She also shared about her family’s attempt to minimize her symptoms, “My family would say ‘this is in you, it is inside your head. You can’t fell this way, you’re well’.” This demonstrates the perpetuated silence and intergenerational stigma around mental health, in which people do not have enough information, do not openly discuss, and attempt to minimize topics related to mental health.
Participants reported that after immigrating to the United States, they started to gain more awareness of mental health due to getting connected with services, as Valentina reported that, “The concept of mental health I actually learned here [in the U.S.]… Now that I’m here I understand what it is. I think, ‘No, that was not ‘a crazy’ ’, but actually someone who wasn’t well from their mental faculties.” Through their lived experience and participation in the workshop, they reported developing a new view of mental health. Participants replaced the intergenerational stigma with normalization, and learned that mental health disorders are conditions like any other health-related
16 matters, as Carmen reported, “I learned that it is a disease like any other disease”. The silence and dismissal were replaced by setting mental health as a priority, as Sofia shared that, “I know that it’s very important, paramount. At any time, from childhood to old age, we might need help... professional help. We shouldn’t think that ‘I’m crazy’ or ‘they will think that I’m crazy.’ No. We’ll always need help.”
Tenemos que Estar Atentos (We Must Pay Attention). The women shared how participation in the workshop taught them about mental health signs and symptoms, and assisted them to recognize when their family or friends needed support, as Valentina shared that, “I learned to be more vigilant, to be aware of those red warning signs, like depression… Now I can detect if my daughter is going through something because of the change in her behavior… Now I’m more alert to things.”
Isabel recounted that, “My oldest daughter would always say, ‘This gives me anxiety’, and
I would think, ‘No, this is not a big deal.’ But then I started to learn about anxiety in the workshop.
And now with my youngest one, I already knew what it was.” By learning the symptoms of anxiety, she was able to move from minimization to recognition of symptoms, which prompted her to engage in early intervention and linkage to formal mental health services, as she added, “I noticed all the symptoms. If I hadn’t taken the classes I wouldn’t have noticed it so quickly. And so I looked for help.”
Carmen reported that by knowing the signs and symptoms of certain diagnoses, she was able to help a neighbor who recently experienced mental health issues. This contributes to a sense of purpose as participants help their community, as she recounted, “For the community, I contribute with what I know, like telling friends about where to get help.” Similarly, Isabel reported experiencing positive feelings as she encouraged others in her community to seek help, “I feel
17 good that I can help her and make sure that this girl gets well.” Thus, by learning about mental health symptoms and being able to recognize when others need assistance, the women are able to encourage others to seek help. In turn, this generates a sense of purpose and positive feelings as the women fell that they have an important role in supporting someone’s recovery.
Help-Seeking and Knowledge of Resources. Help-seeking efficacy—another component of MHL—is often hindered by financial status, as Adriana recounted, “In Guadalajara, unfortunately, you can only access things if you have money.” After immigrating to the United
States, participants reported that they were able to access mental health services as it was more easily available, as Adriana stated that, “I like this country as it has many opportunities that we do not have in our countries as Latinos.” Similarly, Valentina mentioned that, “In Mexico, there are not as many resources as here, there are not many classes or information.” Thus, the environment in which participants are inserted directly affects their help-seeking ability.
The workshop assisted participants to learn about community resources, as Sofia shared that, “The facilitator gave us handouts and talked about the mental health clinic, where there is always someone that can do assessments and refer people to services. She reminded us that we are not alone, that there is always help.” Participation in the workshops helped the women to learn about resources available in the community, thus enhancing their help-seeking ability. The increased knowledge helped them to better navigate the mental health system and to also refer the community to services, as Valentina stated, “Before I didn’t know anything, where to find help, or where one could go for lectures. And now, I’m the one who tells people where to go.”
Adriana shared that despite not personally having extensive information on community resources, she does know that “we can just contact Project Esperanza, and they will refer you to resources.” This demonstrates how the faith-based organization becomes a bridge for the
18 community to get linked to formal mental health services. It becomes a one-stop resource in which participants not only access spiritual services, but also recreational and educational services for children, mental health literacy for families, and services linkage to the community.
Additional reported barriers to help seeking were initial lack of confidence and empowerment to deal with mental health-related matters. Valentina shared about the power dynamic between a mental health provider and her:
The doctor said that my son had ADHD. And in my mind, I would think, “pero no está
loco” (“but he isn’t crazy”). She asked me, “do you have questions?” and I said, “No”. I
actually had questions, but I didn’t even know how to ask or how to talk about that.
Following attendance in the workshops, she reported feeling empowered to ask questions and to advocate for her child’s needs, “If that doctor said the same thing today, I would ask her questions because now I have more knowledge and feel more confident. I would ask, “Why are you giving this diagnosis? Now I no longer stay quiet.”
It is notable that the reported increased confidence, self-esteem, and sense of worth, assisted the participants’ to feel empowered to take an active role in their family’s treatment decision, as Isabel shared:
We all have increased self-esteem, feel more important, feel like we can face whatever
comes our way with the information that we have. The project gives us strength, they tell
us that we have rights; they make us realize that we are worthy. We have to go and ask for
the help that we need.
The development of self-esteem and confidence appeared to be important skills for participants to foster hope, feel empowered to seek services, and actively participate in treatment
19 decisions. In addition to having the theoretical knowledge of mental health, they now have the power and voice to take action to seek help and access resources.
Learning Skills. An additional component of MHL is understanding how to maintain positive mental health. Participants not only learned to recognize mental health symptoms but also how to engage in prevention and self-care. Carmen shared about skills that she learned in the workshops; “In the wellness workshop, we learned to make time for ourselves. Because if we get sick, how can we attend to our family? We need to make time for relaxation. So they taught us guided imagery and breathing techniques.”
The women also learned about the importance of taking care of one’s mental health in order to prevent further somatic issues, as Sofia explained, “Sometimes one gets closed into one’s own problems... and that’s why so many have stress, depression, high blood pressure... We develop so many diseases because we don’t take care of our mental health.”
Learning skills to maintain positive mental health appeared to be a significant intervention, as Latina mothers reported having multiple roles, responsibilities, and often placing other people’s needs above their own. They now place importance on attending to their own needs to ensure that they can continue supporting their family and community.
Development of Support System
An important characteristic of the workshop is its ability to promote an environment of collectivism and familismo, often highly regarded by Latinos. Thus, another subcategory that emerged on the Impact on Individuals was the reported feeling of being among family experienced by participants. Adriana shared that “We laugh, we talk, and at the end, we finish the workshop as family.” Carmen added that, “We are like a family, like a team, we help each other. That’s what matters. We have to be united for our children and for their mental health.”
20 Feeling among family contributes to the development of trust, as Isabel explained, “One feels in ‘confianza’ (safe, comfortable), as if we knew each other from before, even though there are people that we haven’t seen before.” In turn, this trust contributes to a space of mutual help, as
Carmen shared, “I think that we always look for someone to listen to us. We hear each other, share our experiences, and reach a conclusion between us.”
Similarly, Valentina reported that, “When I started to go there, I didn’t know anyone.
People that attend the classes say, ‘oh, I have been through that, this might help you.’ So, we feel like in community, very united.” The environment of sharing and mutual help appeared to be an important factor that assisted participants to develop trust, to feel among family, and to find the solutions within themselves, thus developing a support system based on Latino cultural values.
Impact on Family
Participants reported that the workshop facilitators have always encouraged them to not keep the knowledge built in the workshop for themselves, but to actually share it with their families and community. All women reported that they have been implemented the learned skills in several areas of their lives.
Improved Parenting Practices
Participants described how their worldviews and upbringing initially shaped their parenting skills. There was a common desire of “being a better mother” to not replicate their own parents’ mistakes, as Adriana described:
I realized that as parents we sometimes make mistakes. There’s no book that can guide us
to be good parents. My father used to hit me, and I did not want to be that kind of parent. I
said to myself, “I need to learn how to be patient, to understand that she is a child. I want
21 to be a good mother, to be able to talk to her, listen to her”. Sometimes we don’t listen to
our children, and that’s the worst mistake that we can make.
The barriers that they experienced in their upbringing also influenced their parenting practices. Despite many of them not being able to pursue their educational goals due to gender roles and financial barriers, they now motivate and support their children to academically succeed, as Sofia recounted:
I always wanted to have a profession, but in Mexico we didn’t have the same opportunities
and the economic resources. That’s why I say that if we are in a country that has more
opportunities, my kids must be what I didn’t have the chance to be or do. The more study
they have, the more opportunities and work they will have.
Carmen adds that as mothers, they are focused on learning skills that can help them to provide better opportunities to their offspring. This desire to provide better opportunities goes beyond educational achievement or status, and it also focuses on emotional connection and mental health, as she shared that, “They teach us that we shouldn’t say, ‘don’t cry’. We must let them have all the emotions. I tell my son to breath, calm down, count until 10, or until 100” (laughs).
They teach us these strategies.”
Valentina shared that, “Something that I also learned in the classes is to talk to my children about what happened on their day or ask what they did and tell them that I love them.” Similarly,
Adriana shared that, “I learned how to listen to them [children]. We do not need to start yelling at them. We must ask them, “how are you, how was your day?” And listen to them. And respect their space.”
They also shared about the role of mothers on the family’s mental health. When sharing her thoughts about why there is a significantly higher number of mothers attending the workshop
22 than fathers, Gabriela said that, “I think men, and especially Latinos, are more machistas. They are not very approachable. They say, ‘I don’t need help. I’m well.’ They don’t recognize their mistakes; they don’t accept it. As Latina mothers, we are nobler, more sensitive.”
Carmen added that, “I think that men don’t give much importance to it. As women, we are more sensitive towards mental health”, while Isabel stated that, “It’s always the mothers who are seeking help… But this has been happening forever. All the women I know are always complaining about how men leave everything for the women, at home, and in education.” The women’s statements demonstrate the parental role disparities and gender expectations regarding the offspring education and mental health, in which women are seen as more nurturing and sensitive to address this matters, therefore they are the ones responsible for such tasks in the Latino family.
Break of Intergenerational Stigma
All participants reported that the stigma on mental health had been present for a long time and was passed down through the generations. Valentina talked about the intergenerational mental health stigma that she was exposed to, “I didn’t know what mental health was. One always grows up with one family’s mentality or education. But now my views have changed—it’s not that ‘they are crazy’, but that one really needs help.”
By developing mental health literacy in the workshops, she not only changed her views on mental health, but also learned skills to talk about mental health with her children, and to break the intergenerational stigma that she has been exposed to, “I learned how to talk to my kids about mental health. Because I don’t want it to be like how my mother would say, ‘they are crazy’. I always try to teach them to have empathy for others.”
Through their lived experiences and the mental health literacy developed in the workshops, the women often reported developing empathy towards people who experience mental health
23 challenges. They no longer carry the cultural views based in taboo and stigma, but rather have an open and empathic view towards it. Through education and open communication, they strive to pass this new attitude towards mental health to their offspring, thus breaking the intergenerational stigma.
Impact on Community
Following the same premise of sharing the knowledge built in the workshop, participants’ actions are affecting the community as a whole as they educate, encourage, and link them with services.
One Cannot Make It Alone – Mental Health Awareness
By developing mental health literacy, participants gain skills and feel confident to spread mental health awareness to the community, as Carmen recounted:
When people say that they are not feeling well, I tell them to go to a clinic or talk to their
doctor. I say, “People can’t move forward without help from others. You shouldn’t feel
embarrassed. You have to go and ask for help”, because one cannot make it alone.
Similarly, Isabel stated that when coworkers mention that a family member is experiencing mental health challenges, she tells them, “Look for help, look for help. Because help is available for free. But pay attention now. Because the sooner the better.”
Considering that stigma is a barrier to mental health services utilization among Latinos, the participants’ action of spreading mental health awareness is a significant intervention. Participants encourage the community to no longer have shame, but rather to take action and access help. Since
Latinos value personalismo, receiving mental health information from a friend or coworker with whom there is a relationship of trust increases the likelihood of following through.
24 Engagement with Services
By sharing information about Project Esperanza, the women encourage the community to get connected with meaningful activities and to access services, as Carmen shared, “A lot of people ask me where I take my kids for the taekwondo classes. I tell them that it is low cost and also say,
‘they teach them discipline, respect’. I say, ‘go, take your kid’, I encourage them.”
Sofia, who takes English as second language class in the community, always shares information with her classmates and encourages them to enroll their children in services, “When I give presentations I always talk about the activities that my kids do at Project Esperanza. I give them the address and encourage them to take their kids. I always give them the information.”
Isabel shared about how her mental health literacy skills motivated her to encourage the community to seek mental health services.
At my work, when someone tells me, “Oh, I think my family member is not well”, so I tell
them, “Look for help because help is available for free. Pay attention now, because the
sooner the better. You have to go to the clinic. Do you want me to bring you a card?” And
I feel good that I can help them and make sure their family gets well.
Since lack of knowledge of resources is another barrier that hinders access to services among Latinos, by providing information about resources and offering support to link the community with such services, the women are able to increase the likelihood of the community access to services.
Querer Es Poder (Where There Is a Will There Is a Way) - Advocacy
Women shared how their lived experiences and skills learned at the workshop assisted them to take on an advocacy role. It was noteworthy how all participants experienced several barriers during their upbringing and immigration journey, yet continuously overcame barriers, as
25 Adriana shared that, “I learned that life is hard. Sometimes God doesn’t make things too easy. But
I learned that ‘querer es poder’ (‘where there is a will there is a way’). If you want to overcome something you can do it.”
When recounting their experiences, the women shared about the aspirations they had but were unable to pursue due to their gender. Valentina shared that “I always wanted to learn taekwondo but they never let me because I was a woman. My mom would say, ‘this is for boys’, so they never let me.” Similarly, Sofia talked about her career dreams, “I wanted to go to school to be a teacher or a lawyer. But my parents said I would waste my time, we had no money, and that as a woman I couldn’t be there alone. So I didn’t go.”
This was a particularly significant statement. Throughout the interview, Sofia shared her strong engagement in her children’s education, including being a member of the English Learner
Advisory Committee of the school district. In this advocacy role, she participates in meetings, facilitates workshops on mental health, and advocates for services for minorities. Thus, by providing active listening and reflection, the researcher pointed out to Sofia that she was currently employing the skills of her previous dream career.
By gaining awareness and confidence to deal with mental health-related matters, women started to advocate for services in the community. After noticing that her family member was experiencing anxiety, Isabel advocated for services to be provided at the school:
So that's when I said, “I need her to get therapy.” I also went to the school and they started
to pay attention. I called them and told them what was happening, that she was going
through anxiety. After two weeks she didn’t get any help. So I called them back, spoke
with the teacher, asked for the services, and now they give her therapy once a week.
26 Discussion
The present study examined how participation in a faith-based mental health literacy program affects Latinos. Despite the initial focus of the study on examining the impact on individuals, findings pointed out that the impact of this program surpasses the individual level.
The framework “Mental Health Literacy Ripples From the Individual to Posterity” was the central process that emerged from data, and represented an ecological model (Bronfenbrenner, 1979) of the dynamic interactions between individuals and the environment, and the multilayer influence that an intervention can have. This framework encompasses the impact on the individual, impact on the family, and impact on the community (Figure 1). Each category has several outcomes derived from the faith-based mental health literacy intervention.
Figure 1: Mental Health Literacy Ripples From the Individual to Posterity
27 The skills learned on an individual level are put into practice and generate change at the family level. This, in turn, affects the community as a whole. As individuals feel empowered and confident, they are able to educate the community regarding mental health awareness, advocate for services, and ultimately increase access to formal mental health services. Thus, what started as an intervention for a specific population, evolved into something that has the power to reach entire communities.
Impact on Individual
Mental Health Literacy
Mental Health Literacy (MHL) is defined as understanding how to obtain and maintain positive mental health, understanding mental disorders and their treatments, decreasing stigma related to mental disorders, and enhancing help-seeking efficacy (Jorm et al., 1997). The MHL workshops from Project Esperanza employ techniques based on Brazilian educator Paulo Freire’s
Popular Education (also known as Freirian and empowerment education), which is known for its effectiveness for enhancing empowerment and improving health (Wiggins, 2012). In Popular
Education, all social actors (in this scenario, mental health practitioners, advocates, church staff, parents and community) collectively build knowledge based on practice and sharing of experiences, promoting an active learning environment and fostering empowerment (Freire, 2000).
During the MHL workshop observation, the researcher was able to witness some of its principles in place, as the workshop facilitator validated what participants already know and do and connected participant’s personal experience to larger social realities (Wiggins, 2012). All participants reported that the environment of mutual help assisted them to develop strategies to target their unique challenges, which can be seen as a way to work collectively to change their reality (Wiggins, 2012).
28 Women reported that participation on the MHL workshops assisted them to shift their views on mental health, ultimately reducing the stigma, which is consistent with documented findings that faith-based MHL initiatives can reduce mental illness stigma in minority and underserved communities (Brown, 2009; Jozaghi et al., 2016). They also learned about mental illness signs, symptoms, and treatment, increasing their awareness knowledge of treatment service, which is consistent with findings from Crewe (2006) and Pickett-Schenk (2002).
Overall, the increased mental health literacy among participants can be seen as an important intervention as scholars point that lower levels of health literacy are associated with less likelihood of engaging in preventive behaviors, symptom recognition, accessing resources, and adhering to treatment recommendations (Dearfield et al, 2017).
The increased knowledge about community resources allows participants, families, and the community to access resources. This is an important outcome considering that Latinos have underutilized services, and knowing where to find a provider increases the likelihood of specialty mental health use (Vega et al., 2001). Nevertheless, it is important to not fall into a faulty generalization that Latinos have underutilized services due to individual choices, such as by “not knowing how to access services”. As Aguilar-Gaxiola et al. (2012) caution, mental health care providers must recognize that systemic and institutional structures continue to impede improvements in access and quality of care for the Latino individual, family, and community.
Women reported an increase in self-esteem and confidence, which is aligned with findings from Pickett-Schenk (2002) about the faith-based MHL programs’ ability to improve morale among participants. The MHL workshop assisted participants to develop higher levels of self- esteem, confidence, and empowerment, which is consistent with several studies that used popular education in a public health context (Wiggins, 2012). Women recounted their initial lack of
29 confidence to deal with mental health-related issues when interacting with providers. As Dearfield et al. (2017) suggest, the patient’s level of health literacy affects the quality of care they receive, as patients with low health literacy tend to be less proactive in communicating their health needs.
Additionally, as Allen and Spitzer (2016) propose, due to Latinos’ high degree of respect for authority (respecto), patients may be hesitant to ask questions and may indicate agreement with treatment and recommendations in order to avoid being disrespectful to a provider, despite not truly agreeing or even understanding the plan. As women participated in the workshop, they developed confidence and changed the way they interact with providers, taking an active role on their families’ treatment, which can impact treatment outcomes as Sanders and colleagues (2009) pose that children of parents who have high levels of health literacy have better outcomes related to child health promotion and disease prevention.
Development of Support System
The workshop environment based on cultural values and on mutual help assisted women to develop a support system and foster a feeling of being “among family”, as they reported. This is an important characteristic that leads to successful interventions, Ayón et al. (2010) suggest that by developing and implementing programs grounded in the values and strengths of the
Latino culture, such as familismo, barriers to accessing and utilizing mental health services may be reduced or eliminated.
Impact on Family
Improved parenting practices
Previous research on faith-based MHL did not report effects on parenting practices. This can be due to the uniqueness of each program and its curriculums. It might also speak to the uniqueness of programs geared towards Latinos, who place high importance on familismo, and
30 also to the nature of this particular program which is for parents of children who attend the after school program. Thus, parenting skills have been included in its classes. This intervention outcome is relevant as positive parenting practices have a significant impact on offspring developmental outcomes and mental health (Smokowski et al., 2015).
The current study findings demonstrate that women are the ones responsible for the children’s education and mental health, due to being more “sensitive”. This can be associated with beliefs and attitudes ingrained in machismo that consider appropriate for women to take on traditional roles. According to Nuñez et al. (2016), machismo and marianismo are socially acceptable norms and beliefs that foster traditional gender roles and a patriarchal power structure, as it considers appropriate for women to remain in traditional home and family- centered roles, and be the source of strength and the main responsible for the family wellbeing and spiritual. The women’s openness and sensitivity to deal with mental health are also consistent with studies that found that among Latinos, women are more likely than men to use mental health services (Ortega & Alegria, 2002; Peifer et al., 2000; Vega et al., 2001).
Break of Intergenerational Stigma
Previous research has not focused on the intergenerational characteristic of stigma, thus not generating findings in regards to this outcome for faith-based MHL programs. Nevertheless, considering the intense mental health stigma prevalent among Latinos (Kouyoumdjian et al.,
2003), this outcome was significant in this research. The break of intergenerational stigma is relevant as Vega and colleagues (2010) found that Latinos fearing stigma are less likely to acknowledge their condition and more likely to avoid treatment. By replacing the silence and stigmatized view of mental health with normalization and open communication, these mothers are
31 changing the way Latino families approach mental health. They are fostering an environment of acceptance and empathy while striving to access services that can improve mental health.
Impact on Community
Although Dearfield et al. (2017) claim that the desired impact of health literacy is to not only change individual health behavior but also community behavior change, previous research on faith-based mental health literacy has not focused on the community impact. Thus, the current study findings extend the existing literature.
Increased Mental Health Awareness
As participants develop mental health literacy, they share their knowledge with the community, destigmatize mental health, and provide information on community resources. Based on the value of personalismo, Latinos place great emphasis on personal relationships (Evans et al.,
2007), and tend to first seek informal mental health sources of help, such as family, friends, or faith leader (Cabassa & Zayas, 2007). Thus, receiving the information from someone they trust might increase their awareness of mental health, as Cabassa and Zayas (2007) suggest that the advice, information, and pressures provided by individuals close to the patient have such a positive impact on help-seeking decisions.
Engagement with Services
In face of the historical and prevalent underutilization of mental health services among
Latinos, Project Esperanza serves as the bridge to formal services and mitigates the utilization disparities. This happens as participants encourage the community to engage their children in the afterschool activities and to participate in the MHL workshops, as they destigmatize mental health, and as they encourage people to seek mental health services, often offering a warm hand-off to services. Additionally, Project Esperanza’s staff also provides warm hand-off and links the
32 community with formal mental health services, and has made 224 clinical referrals between 2016 and 2017 (Ventura County Behavioral Health, 2018).
Advocacy
The awareness and empowerment derived from mental health literacy impact on the individual level motivated women to take active roles in their communities. According to Wiggins
(2012), several studies associated popular education interventions with gaining greater control over one’s life, representing a step toward collective action, in that community members take leadership roles. This can be seen in Sofia’s leadership role in her children’s school committee and on Isabel’s advocacy for mental health services in the school.
In summary, this research is not only consistent with previous findings regarding the ability of faith-based mental health literacy initiatives to reduce mental illness stigma in minority and underserved communities (Brown, 2009; Jozaghi et al., 2016), increase mental health awareness and knowledge of treatment service (Crewe, 2006; Pickett-Schenk, 2002), and improve morale
(Pickett-Schenk, 2002) among participants, but also extends the literature as it suggests that such initiatives are also capable of improving parenting practices, decreasing intergenerational stigma and increasing access to formal mental health services.
33 Implications
This study fills some of the existing gaps on the lack of documented practices in the literature using a qualitative research method focused on the effects of faith-based interventions on minority groups. The findings point to the positive ripple effect of faith-based MHL interventions on individuals, families, and communities, with the emergence of an ecological framework of the multilayer impact on a micro, mezzo and macro level is relevant to the social work field. The findings are also a reminder for social workers to practice from a strengths perspective and assess the assets present in the communities where they are inserted.
Despite having the necessary skills and expertise, social workers do not yet have a visible presence in the area of mental health literacy (Mendenhall & Frauenholtz, 2013). Guided by the principles of competence, importance of human relationships, and social justice (National
Association of Social Workers [NASW], 2017), social workers must aim to provide evidence- based services geared to the unique characteristics of the community which they serve, while striving to mitigate the service gaps prevalent in vulnerable and oppressed groups. Thus, delivering faith-based mental health literacy becomes a quintessential intervention that can provide awareness, prevention, and linkage to formal mental health treatment.
On a micro level, social workers can engage with faith-based programs to increase individuals’ access to formal mental health services, as Caplan and Cordero (2015) argue that involvement of the faith-based community should be a fundamental piece of mental health literacy interventions to improve treatment engagement among Latinos. By linking individuals with such services, social workers can exercise the values of importance of human relationships and dignity and worth of the person (NASW, 2017) as they support individuals to build onto their cultural identity strengths and develop mental health literacy, support system, and empowerment.
34 Additionally, based on the value of service (NASW, 2017), social workers can provide pro bono services in these programs and serve as guest lecturers in MHL workshops.
On a mezzo level, when working with families, social workers can link them with programs such as Project Esperanza as it has the potential to impact the entire family system and involve all members in meaningful activities. Additionally, social workers can partner with faith-based initiatives and bring several community actors (families, churches, schools, and behavioral health agencies) together as partners in the helping process and change. Thus, implementing a comprehensive system of care for Latinos focused on building on existing community assets and resources to improve access to care, as recommended by Aguilar-Gaxiola et al. (2012).
Finally, social workers acting on a macro level can focus on program development, evaluation, research, and policy analysis. As the WHO (2019) poses that governments should develop policies to fund programs that promote health literacy particularly among vulnerable communities, social workers can act advocates and lobby for policies that address social justice in a mental health context.
35 Limitations
This study is subject to certain limitations as its qualitative nature yields limited generalizability. While the small size of the purposive sampling was appropriate for the study aims, further research is needed to expand the emergent theory among other Latino groups from different ages, generations, geographic location, and religions. One-on-one interviews feature certain limitations as the reported data is a result of a construction—or reconstruction—of a reality
(Charmaz, 2014), and are also subject to recall and social desirability bias. Moreover, the power dynamic between the researcher and participants should not be ignored. Despite certain common identities (Latino ethnicity, woman, and immigrant), the researcher brings several socially privileged identities that may have affected the interview dynamic and how findings were analyzed. Scholars should consider incorporating longitudinal studies to analyze the long-term effects of faith-based initiatives to support Latino mental health, and including mixed methods to add methodological rigor.
Nevertheless, it is important to highlight the strengths of this study. The one-on-one in- depth interviews yielded data that enhanced comprehensiveness and understanding of the reality of the participants, and the triangulation of data sources increased credibility. Most of all, this research served to magnify the voices of the often unheard—Latinos, women, monolingual
Spanish speaking, and immigrants. As Charmaz (2014) poses, interviews validate the participant’s humanity, perspective, or action. All participants reported enjoying the experience of sharing their stories and helping the researcher. By providing active listening and reflection, the researcher assisted the participants to reframe certain aspects of their journey and recognize the impact that they have made on their families and community
36 Conclusion
This study examined the impact of community faith-based initiatives on Latino mental health. The findings contribute insight into the importance of utilizing interventions based on
Latino values that can have positive effects on prevention, early intervention, and mental health treatment. As a qualitative research, this study serves to magnify the voices of the often unheard and brings attention to the significant role of Latina mothers in the mental health realm—which goes beyond caregiving duties and moves towards advocacy and community leadership.
The main theoretical process focuses on an ecological model of the impact that faith-based mental health literacy programs have on the individual, family and community level. In this context, faith-based organizations are able to serve as a bridge that links families with formal mental health services that have been historically underutilized among Latinos. The findings can assist social workers, policymakers and governments to develop, fund, advocate, and support faith- based programs that can overcome the social barriers, bridge the services gaps, empower groups, and foster social justice for vulnerable and oppressed communities.
37 References
Aguilar-Gaxiola, S., Loera, G., Méndez, L., Sala, M., Latino Mental Health Concilio, and
Nakamoto, J. (2012). Community-Defined Solutions for Latino Mental Health Care
Disparities: California Reducing Disparities Project, Latino Strategic Planning
Workgroup Population Report. Sacramento, Ca: UC Davis, 2012.
Alegría, M., Chatterji, P., Wells, K., Cao, Z., Chen, C., Takeuchi, D., . . . Meng, X. (2008).
Disparity in Depression Treatment Among Racial and Ethnic Minority Populations in the
United States. Psychiatric Services, 59(11), 1264-1272.
Allen, K.M. & Spitzer, W.J. (2016). Social work practice in healthcare: Advanced approaches
and emerging trends. Thousand Oaks, CA: Sage Publications. ISBN-10:
1483353206/ISBN-13: 978-1483353203
Ayón, C., Marsiglia, F., & Bermudez‐Parsai, M. (2010). Latino family mental health: Exploring
the role of discrimination and familismo. Journal of Community Psychology, 38(6), 742-
756.
Bronfenbrenner, U. (1979). The Ecology of Human Development: Experiments by Nature and
Design. Cambridge, MA: Harvard University Press.
Brown, J. (2009). Faith‐based mental health education: A service‐learning opportunity for
nursing students. Journal of Psychiatric and Mental Health Nursing, 16(6), 581-588.
Cabassa, L., & Zayas, L. (2007). Latino Immigrants’ Intentions to Seek Depression Care.
American Journal of Orthopsychiatry, 77(2), 231-242.
Caplan, S., & Cordero, C. (2015). Development of a Faith-Based Mental Health Literacy
Program to Improve Treatment Engagement Among Caribbean Latinos in the
Northeastern United States of America. International Quarterly of Community Health
38 Education, 35(3), 199-214.
Carbado, D., Crenshaw, K., Mays, V., & Tomlinson, B. (2013). INTERSECTIONALITY:
Mapping the Movements of a Theory. Du Bois Review: Social Science Research on Race,
10(2), 303-312. doi:10.1017/S1742058X13000349
Charmaz, K. (2014). Constructing grounded theory. London: SAGE.
Clark, V. L. P., & Creswell, J. W. (2015). Understanding Research: A Consumer's Guide.
Boston: Pearson Education, Inc.
Clarke, A. (1991). Social worlds/arenas theory as organizational theory. In Maines, D. (ed.)
Social organization and socials process: essays in honor of Anselm Strauss. Hawthorne
(NY): Aldine de Gruyter
Cole, E. (2009). Intersectionality and Research in Psychology. American Psychologist, 64(3),
170-180.
Creswell, J. W., & Poth, C. N. (2018). Qualitative inquiry and research design: choosing
among five approaches. Los Angeles, CA: Sage.
Crewe, S. E. (2006). Joy of living: A community-based mental health promotion program for
African American elders. Journal of Gerontological Social Work, 48, 421–438.
doi:10.1300/J083v48n03_09
Dearfield, C., Barnum, A., & Pugh-Yi, R. (2017). Adapting Paulo Freire’s Pedagogy for
Health Literacy Interventions. Humanity & Society, 41(2), 182-208.
Escovar, E., Craske, M., Roy-Byrne, P., Stein, M., Sullivan, G., Sherbourne, C., . . . Chavira, D.
(2018). Cultural influences on mental health symptoms in a primary care sample of
Latinx patients. Journal of Anxiety Disorders, 55, 39-47.
39 Evans, B., Coon, D., & Crogan, N. (2007). Personalismo and Breaking Barriers: Accessing
Hispanic Populations for Clinical Services and Research. Geriatric Nursing, 28(5), 289-
296.
Freire, P. (2000) Pedagogia do Oprimido. 29. ed. Rio de Janeiro, São Paulo: Paz e Terra, 2000.
Furnham, A., & Swami, V. (2018). Mental Health Literacy: A Review of What It Is and Why It
Matters. International Perspectives in Psychology: Research, Practice, Consultation, 7(4),
240-257.
Glaser, B. (1965). The Constant Comparative Method of Qualitative Analysis. Social Problems,
12(4), 436-445.
Hunting, G. (2014). Intersectionality-informed qualitative research: A primer. Vancouver, BC:
Institute for Intersectionality Research and Policy, Simon Fraser University.
Jozaghi, E., Asadullah, M., & Dahya, A. (2016). The role of Muslim faith-based programs in
transforming the lives of people suffering with mental health and addiction problems.
Journal of Substance Use, 21(6), 587-593.
Jorm, A. F., Korten, A. E., Jacomb, P. A., Christensen, H., Rodgers, B., & Pollitt, P.
(1997).“Mental health literacy”: A survey of the public’s ability to recognize mental
disorders and their beliefs about the effectiveness of treatment. Medical Journal of
Australia, 166, 182–186.
Keyes, C., & Ryff, C. (2003). Somatization and mental health: A comparative study of the idiom
of distress hypothesis. Social Science & Medicine, 57(10), 1833-1845.
Kirmayer, L., & Young, A. (1998). Culture and Somatization: Clinical, Epidemiological, and
Ethnographic Perspectives. Psychosomatic Medicine,60(4), 420-430.
40 Kouyoumdjian, H., Zamboanga, B., & Hansen, D. (2003). Barriers to Community Mental Health
Services for Latinos: Treatment Considerations. Clinical Psychology: Science and
Practice, 10(4), 394-422
Mendenhall, A., & Frauenholtz, S. (2013). Mental Health Literacy: Social Workʼs Role in
Improving Public Mental Health. Social Work, 58(4), 365-368.
Mori, L., Panova, A., & Keo, Z. S. (2007). Perceptions of mental illness and psychotherapy in a
sample of Asian, Hispanic, and White American college students. Journal of Psychiatry
Psychology and Mental Health, 1, 1–13.
National Alliance on Mental Illness. (n.d.). Latino Mental Health. Retrieved from
https://www.nami.org/find-support/diverse-communities/latino-mental-health.
National Association of Social Workers (2017). Code of ethics of the National Association of
Social Workers. Washington, D. C.
Nuñez, A., González, P., Talavera, G., Sanchez-Johnsen, L., Roesch, S., Davis, S., . . . Gallo, L.
(2016). Machismo, Marianismo, and Negative Cognitive-Emotional Factors: Findings
From the Hispanic Community Health Study/Study of Latinos Sociocultural Ancillary
Study. Journal of Latina/o Psychology, 4(4), 202-217.
O’connor, M., & Casey, L. (2015). The Mental Health Literacy Scale (MHLS): A new scale-
based measure of mental health literacy. Psychiatry Research, 229(1-2), 511-516.
Ortega, A., & Alegría, N. (2002). Self-Reliance, Mental Health Need, and the Use of Mental
Healthcare Among Island Puerto Ricans. Mental Health Services Research, 4(3), 131-
140.
Peifer, K., Hu, T., & Vega, W. (2000). Help Seeking by Persons of Mexican Origin With
Functional Impairments. Psychiatric Services, 51(10), 1293-1298
41 Pickett-Schenk, S. (2002). Church-Based Support Groups for African American Families Coping
with Mental Illness: Outreach and Outcomes. Psychiatric Rehabilitation Journal, 26(2),
173-180.
Sanders, L., Shaw, J., Guez, G., Baur, C., & Rudd, R. (2009). Health literacy and child health
promotion: Implications for research, clinical care, and public policy. Pediatrics, 124
Suppl 3(3), S306-S314.
Shin, R. Q., Welch, J. C., Kaya, A. E., Yeung, J. G., Obana, C., Sharma, R.,...Yee, S. (2017). The
intersectionality framework and identity intersections in the Journal of Counseling
Psychology and The Counseling Psychologist: A content analysis. Journal of Counseling
Psychology, 64,458–474.http://dx.doi.org/10.1037/cou0000204
Smokowski, P., Bacallao, R., Cotter, M., & Evans, L. (2015). The Effects of Positive and
Negative Parenting Practices on Adolescent Mental Health Outcomes in a Multicultural
Sample of Rural Youth. Child Psychiatry & Human Development, 46(3), 333-345.
Substance Abuse and Mental Health Services Administration. (2018). Key substance use and
mental health indicators in the United States: Results from the 2017 National Survey on
Drug Use and Health (HHS Publication No. SMA 18-5068, NSDUH Series H-53).
Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse
and Mental Health Services Administration. Retrieved from
https://www.samhsa.gov/data/
Substance Abuse and Mental Health Services Administration. (2019, April 19). Faith-Based
Coalitions and Collaborative Partnerships. Retrieved from https://www.samhsa.gov/faith-
based-initiatives/training-technical-assistance/coalitions-collaboratives.
42 U.S. Census Bureau. (2010). QuickFacts Santa Paula city, California; United States. Retrieved
from
https://www.census.gov/quickfacts/fact/table/santapaulacitycalifornia,US/PST045218
U.S. Census Bureau. (2018, October 4). Hispanic Heritage Month 2018. Retrieved from
https://www.census.gov/newsroom/facts-for-features/2018/hispanic-heritage-month.html.
Vega, W., Kolody, A., & Aguilar-Gaxiola, B. (2001). Help Seeking for Mental Health Problems
Among Mexican Americans. Journal of Immigrant Health, 3(3), 133-140.
Vega, W. A., Rodriguez, M. A., & Ang, A. (2010). Addressing stigma of depression in Latino
primary care patients. General Hospital Psychiatry, 32(2), 182–191.
Ventura County Behavioral Health. (2018). Mental Health Services Act (MHSA) Fiscal Year
2018/19 Update. Retrieved from:
http://www.vchca.org/images/BH/PDF/MHSA/Annual_Report_18-19_using_16-
17_data.FinalETS041318_.pdf
Villatoro, A., Dixon, E., & Mays, V. (2016). Faith-Based Organizations and the Affordable Care
Act: Reducing Latino Mental Health Care Disparities. Psychological Services, 13(1), 92-
104.
Vygotsky, L.S. (1978). Mind in Society. Cambridge, MA: Harvard University Press.
Wang, P., Berglund, P., & Kessler, R. (2003). Patterns and Correlates of Contacting Clergy for
Mental Disorders in the United States. Health Services Research, 38(2), 647-673.
Whittemore, R., Chase, S. K., & Mandle, C. L. (2001). Validity in Qualitative Research.
Qualitative Health Research, 11(4), 522–537.
https://doi.org/10.1177/104973201129119299
43 Wiggins, N. (2012). Popular education for health promotion and community empowerment: A
review of the literature. Health Promotion International, 27(3), 356-371.
Wong, E., Fulton, B., & Derose, K. (2018). Prevalence and Predictors of Mental Health
Programming Among U.S. Religious Congregations. Psychiatric Services (Washington,
D.C.), 69(2), 154-160.
World Health Organization. (2019). Health Literacy. Retrieved from
https://www.who.int/healthpromotion/health-literacy/en/.
World Health Organization. (2005). Promoting mental health: concepts, emerging evidence,
practice: a report of the World Health Organization, Department of Mental Health and
Substance Abuse in collaboration with the Victorian Health Promotion Foundation and
the University of Melbourne / [editors :Helen Herrman ,Shekhar Saxena ,Rob Moodie .
Geneva :World Health Organization.
Zuvekas, S. H., & Fleishman, J. A. (2008). Self-Rated Mental Health and Racial/Ethnic
Disparities in Mental Health Service Use. Medical Care, 46(9), 915-923.
44 Appendix A
Table 1
Characteristics of study sample.
Characteristics N % Sex Female 5 100 Age 39-45 3 60 46-50 2 40 Marital Status Married 5 100 Number of Children 1 1 20 2 2 40 3 1 20 4 1 20 Education Level Middle School 1 20 High School 2 40 Technical School 1 20 Some College 1 20 Employment Status Stay at home mother 3 60 Part-time employment 1 20 Full-time employment 1 20 Country of Origin Mexico 5 100 Language Spanish 5 100
45 Appendix B
Research Invitation
46
47 Appendix C
Interview Protocol (English)
Time of interview:
Date:
Place:
Interviewee:
[Discuss confidentiality, privacy, consent, research goals]
Questions:
1. Growing up, what did you learn or hear about mental health?
2. Before participating in the workshop, what would come into your mind when you thought of “mental health”?
3. After participating in the workshop, what do you understand as “mental health”?
4. How do you describe your experience of participating in the workshop?
5. How did your knowledge about community resources change after participating in the workshop?
6. How did it affect your sense of social support?
7. How did it affect your level of confidence to deal with potential mental health related matters?
8. What were the most important things that you learned in the workshops?
9. How are you planning to apply the information that you learned in your daily life?
10. What are your thoughts about faith-based initiatives that focus on mental health literacy?
48 Protocolo de Entrevista (Español)
Hora de entrevista:
Fecha:
Sitio:
Entrevistado:
[Discutir confidencialidad, privacidad, consentimiento, objetivos de investigación]
Preguntas:
1. Al crecer, ¿qué aprendiste o escuchaste sobre la salud mental?
2. Antes de participar en el taller, ¿qué se te vino a la mente cuando pensaste en "salud mental"?
3. Después de participar en el taller, ¿qué comprendes sobre "salud mental"?
4. ¿Cómo describe su experiencia de participar en el taller?
5. ¿Cómo cambió su conocimiento sobre los recursos de la comunidad después de participar en el taller?
6. ¿Cómo afectó su sentido de apoyo social?
7. ¿Cómo afectó su nivel de confianza para tratar de asuntos potenciales relacionados con la salud mental?
8. ¿Cuáles fueron las cosas más importantes que aprendiste en los talleres?
9. ¿Cómo planea aplicar la información que aprendió en su vida diaria?
10. ¿Qué tan importante crees que son las iniciativas basadas en la fe que proporcionan educación en salud mental?
49 Appendix D
Project Esperanza Mental Health Workshop Agenda (English)
50 Project Esperanza Mental Health Workshop Agenda (Spanish)
51